THE VALIDITY OF ROUTINE MEDICAL CHECKS AND EDUCATION Routine Medical Checks and Education have shown that attempts to retract the foreskin at an early enough age result in a significant decrease in the incidence of phimosis. Monitoring boys before puberty encourages awareness and stimulates the self manipulation which in some cases, is necessary to stretch a phimosis. (It will also allow any persisting problem to be treated in good time before puberty - allowing a healthy preparation for manhood.) The usual medical approach of checking early and preventing when possible is of particular relevance to this subject, where in some cases, checking will provide an education which will promote prevention. next short solution It appears routinely checking children for potential problems is an attitude which was last urgently recommended by Schöberlein (1966) and Bokström (1944). This recommendation was superseded ironically by one remarkable study by Jacob Øster. Ironically because it actually shows an even more urgent need to monitor. __________________________________ Øster: Statistics and Misinterpretations The conclusions and statistics from one study by Jacob Øster are mirrored in publications from Dr. Spock's Baby Book (still today a best seller) to the British Medical Journal. In 1968 Jacob Øster (26) reported on a group of almost two thousand boys aged between 6 and 10 yrs. old. He studied them for a period of 7 to 8 years till they were between 13 and 17 years old. He reported decreasing frequencies for three separate categories of foreskin restriction: phimosis, tight prepuce, and adhesions. Many modern medical studies quote Øster's figures as 1%; sometimes referring to "retractile foreskin", implying phimosis (Gordon and Collin (24),), at other times to "natural separation", implying epithelial adhesions (Warren and Bigelow (27),). Such confusion was partly caused by Øster who presented three separate columns of statistics, and never gave an overall figure, in addition he states, for example regarding 16-17 year-olds: "tight foreskin was present in 2%" whereas in his table of statistics he gives 1%; an analysis shows that in fact this was 1.4%. Whatever his mathematical failings might have been, his study showed in a revolutionary way, that phimosis was not necessarily an indication for circumcision. Øster wrote "Phimosis is seen to be uncommon in schoolboys, and the indications for operation even rarer if the normal development of the prepuce is patiently awaited." This attitude has unfortunately frequently been accepted on face value, one modern medical text even went as far as to interpret this as meaning simply "ignoring" such conditions and their symptoms (24). ___________________________ A Re-Interpretation of Øster Schöberlein (28) says that "in medical examinations of 3,000 young men, mostly of an age between 18 and 22 years . . . A phimosis was found in 8.8%." Beauge (29) was "in charge for over ten years of the routine examination of college freshmen", he "observed several hundred cases". He reports "Inability to retract the foreskin . . . persists in about 10% of the subjects at the end of adolescence." Three other studies covering altogether over 2,200 men, each report frequencies of over 8% with phimosis, significantly all these three unrelated studies report "It was completely unknown to some of the examined boys that the foreskin could be retracted" (Saitmacher). "The ignorance of these young soldiers is remarkable, many of them expressed suprise at the condition revealed when they retracted their foreskins: some of them had apparently never done so in their lives" (Osmond). "most patients were unaware that the prepuce was retractable" (Parkash). If phimosis is largely self resolving (as claimed by Øster), why do the other studies report such high figures? It is clear that Øster influenced his own study. He tells us "the boys received regular instruction about preputial hygiene" coupled with this the boys were physically examined every year. This caring attention and instruction started previous to puberty. This appears to have helped relieve phimosis to some extent and encourage the early release of adhesions. At the very least the physical examinations with the gentle attempts at retraction, would certainly have been an education for those boys who had not realised that their foreskin could retract. It appears that phimosis occurs at a rate of 1% in 17 yr.olds, when these boys have been examined and educated for the previous seven years. Øster states "The object here was to investigate the incidence of preputial `adhesions`, phimosis, and smegma production in an unselected group." While he realises "our actual figures for the incidence of smegma can only be of limited significance, as the boys received regular instruction about preputial hygiene." he does not apply this principle to phimosis - he does not realise that his education may also have influenced the frequency of phimosis among this very lucky selected group of boys. Beauge, after describing how young men with phimosis do not retract the foreskin during masturbation, reports that instruction about this, cured a large number of his patients. He wrote "It would appear then that phimosis . . . diminishes in frequency with age due to the fact of the manipulation of the penis." Conclusion Due to the anatomical difficulties involved it is clear that many boys, some youths and even a few grown men are not aware of the possibility of retraction (medical reports; e.mail examples, analysis). It is reasonable to assume that education about retraction precedes the self manipulation which is in some cases necessary to stretch a phimosis. A medical examination is a very simple and practical way of educating young children that retraction is possible. The sooner that the process of monitoring a child's ability to retract his foreskin could begin, the more possibility the child would have of developing a healthy foreskin which required no correction at a later stage. The optimal time to begin monitoring and educating a boy's ability to retract his foreskin would be while his skin structures are flexible and developing. The medical approach of checking early and preventing when possible is of particular relevance to this subject, where in some cases, checking provides an education which will promote prevention. AN ENCYCLOPEDIA OF PHIMOSIS STATISTICS A review of every medical study with original measurements on phimosis frequencies since 1920. Please note the repititions of Oster's mistake: modern studies quoting and misquoting Øster leading to general misunderstandings about statistics. I showed this information first in 1997 on the NGs, no-one could or has ever disagreed. Every discussion or criticism will be published.